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psnet.ahrq.gov/node/34638/psn-pdf
December 23, 2008 - What is accountability in health care?
December 23, 2008
Emanuel EJ, Emanuel LL. What is accountability in health care? Ann Intern Med. 1996;124(2):229-239.
https://psnet.ahrq.gov/issue/what-accountability-health-care
This perspective details the concepts surrounding “accountability” in health care. The discussion …
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psnet.ahrq.gov/node/50625/psn-pdf
November 06, 2019 - Pediatric medication safety considerations for
pharmacists in an adult hospital setting.
November 6, 2019
Kennedy AR, Massey LR. Pediatric medication safety considerations for pharmacists in an adult hospital
setting. Am J Health Syst Pharm. 2019;76(19):1481-1491. doi:10.1093/ajhp/zxz168.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/48194/psn-pdf
August 28, 2019 - Framing of clinical information affects physicians'
diagnostic accuracy.
August 28, 2019
Popovich I, Szecket N, Nahill A. Framing of clinical information affects physicians' diagnostic accuracy.
Emerg Med J. 2019;36(10):589-594. doi:10.1136/emermed-2019-208409.
https://psnet.ahrq.gov/issue/framing-clinical-informa…
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psnet.ahrq.gov/node/72787/psn-pdf
May 01, 2018 - The Caregiver Advise, Record, Enable (CARE) act.
May 1, 2018
Anthony M. The Caregiver Advise, Record, Enable (CARE) Act. Home Healthc Now. 2018;36(2):69-70.
doi:10.1097/nhh.0000000000000655.
https://psnet.ahrq.gov/issue/caregiver-advise-record-enable-care-act
Home healthcare is an increasingly viable option for pa…
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psnet.ahrq.gov/training-catalog/safety-pediatric-dental-care
August 10, 2025 - Safety in Pediatric Dental Care
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Organization:
Organization
American Academy of Pediatric Dentistry
Event Description: Th…
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psnet.ahrq.gov/web-mm/urinary-retention-dilemma
March 01, 2013 - Urinary Retention Dilemma
Citation Text:
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
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psnet.ahrq.gov/node/49594/psn-pdf
December 01, 2009 - Standard Deviations
December 1, 2009
Sabin JE. Standard Deviations. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/standard-deviations
Case Objectives
Understand the safety risks associated with patients being discharged against medical advice
(AMA).
Recognize safety risks associated with being part of a …
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psnet.ahrq.gov/node/73953/psn-pdf
October 27, 2021 - Deprescribing as a Patient Safety Strategy
October 27, 2021
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
Background
Polypharmacy is defined as the act of taking five or more medications on a regular basis…
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psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
March 25, 2020 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules
Citation Text:
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/node/49693/psn-pdf
October 01, 2013 - It's Sarah, Not Stephen!
October 1, 2013
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/its-sarah-not-stephen
Case Objectives
Define and distinguish the terms gender identity, gender expression, and gender variance.
Delineate patient safety issues associated with transge…
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psnet.ahrq.gov/node/837607/psn-pdf
June 29, 2022 - Common Formats for Event Reporting - Diagnostic Safety
Version 1.0
June 29, 2022
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/common-formats-event-reporting-diagnostic-safety-version-10
Effective measurement of diagnostic error is essential for understanding the problem and genera…
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psnet.ahrq.gov/node/40769/psn-pdf
March 21, 2012 - Identification of adverse events in ground transport
emergency medical services.
March 21, 2012
Patterson PD, Weaver MD, Abebe K, et al. Identification of adverse events in ground transport emergency
medical services. Am J Med Qual. 2011;27(2):139-146. doi:10.1177/1062860611415515.
https://psnet.ahrq.gov/issue/ide…
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psnet.ahrq.gov/node/44272/psn-pdf
November 06, 2015 - Technology, cognition and error.
November 6, 2015
Coiera E. Technology, cognition and error. BMJ Qual Saf. 2015;24(7):417-22. doi:10.1136/bmjqs-2014-
003484.
https://psnet.ahrq.gov/issue/technology-cognition-and-error
Providers and policymakers have raised concerns about risks associated with health information
t…
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psnet.ahrq.gov/node/40234/psn-pdf
April 04, 2011 - Early cost and safety benefits of an inpatient electronic
health record.
April 4, 2011
Zlabek JA, Wickus JW, Mathiason MA. Early cost and safety benefits of an inpatient electronic health
record. Journal of the American Medical Informatics Association. 2011;18(2).
doi:10.1136/jamia.2010.007229.
https://psnet.ahrq…
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psnet.ahrq.gov/node/39968/psn-pdf
November 03, 2010 - Pharmacists' interventions in prescribing errors at
hospital discharge: an observational study in the context
of an electronic prescribing system in a UK teaching
hospital.
November 3, 2010
Abdel-Qader DH, Harper L, Cantrill JA, et al. Pharmacists' interventions in prescribing errors at hospital
discharge: an obs…
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psnet.ahrq.gov/node/74232/psn-pdf
January 12, 2022 - Intersystem medical error discovery: a document analysis
of ethical guidelines.
January 12, 2022
Duffy B, Miller J, Vitous CA, et al. Intersystem medical error discovery: a document analysis of ethical
guidelines. J Patient Saf. 2021;17(8):e1765-e1773. doi:10.1097/pts.0000000000000625.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/34927/psn-pdf
June 23, 2009 - Health Care Quality and Disparities: Lessons from the
First National Reports.
June 23, 2009
Kelley E, Moy E, Dayton E, et al. Med Care. 2005:43(3):I1-I88.
https://psnet.ahrq.gov/issue/health-care-quality-and-disparities-lessons-first-national-reports
Highlights from AHRQ's two inaugural reports, the 2003 National …
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psnet.ahrq.gov/node/40977/psn-pdf
January 12, 2012 - Identification by families of pediatric adverse events and
near misses overlooked by health care providers.
January 12, 2012
Daniels JP, Hunc K, Cochrane D, et al. Identification by families of pediatric adverse events and near
misses overlooked by health care providers. CMAJ. 2012;184(1):29-34. doi:10.1503/cmaj.11…
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psnet.ahrq.gov/node/47289/psn-pdf
October 24, 2018 - ASHP guidelines on managing drug product shortages.
October 24, 2018
Fox ER, McLaughlin MM. ASHP guidelines on managing drug product shortages. Am J Health Syst Pharm.
2018;75(21):1742-1750. doi:10.2146/ajhp180441.
https://psnet.ahrq.gov/issue/ashp-guidelines-managing-drug-product-shortages
Drug shortages are a pe…
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psnet.ahrq.gov/node/45481/psn-pdf
September 14, 2016 - "Use as directed" can cause confusion for both patients
and practitioners.
September 14, 2016
ISMP Medication Safety Alert! Acute Care Edition. August 25, 2016;21:1-3.
https://psnet.ahrq.gov/issue/use-directed-can-cause-confusion-both-patients-and-practitioners
Reporting the results of a survey on "as directed" in…